Medical Health History Questionnaire - University of Texas at Dallas

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2013-2014 VIII. Cardiovascular Risk Factors: Have you ever had chest pain and/or shortness of breath during or after exercise / practice? YES NO ♦ Please Describe Have you ever felt dizzy, lightheaded, and/or passed out during or after exercise / practice? YES NO ♦ Please Describe Have you ever had the feeling of your heart racing or skipping beats during or after exercise / practice? YES NO ♦ Please Describe Do you get tired more quickly than your teammates / friends do during exercise / practice? YES NO ♦ Please Describe Have you ever been told that you have a heart murmur? YES NO ♦ Please Describe Has any family member or relative died of heart problems and/or of sudden death before age 40? YES NO ♦ Please Describe Has a physician ever denied or restricted your participation in sports due to any heart problems? YES NO ♦ Please Describe Have you ever had an electrocardiogram (EKG) or Echo of your heart? YES NO ♦ Dates / Please Describe Have you ever been told that you have / had high blood pressure? YES NO ♦ Please Describe Have you ever been told that you have / had high blood cholesterol? YES NO ♦ Please Describe IX. Head Injuries / Concussion: History of Head Injury/Concussion Injury? YES NO ♦ List Dates/Time Missed ♦ Please Describe Were Any Diagnostic Tests Performed? YES NO (check all that apply) MRI CT-Scan Neuropsychological Testing Other Have You Ever Been Hospitalized, Knocked Out, Become Unconscious, and/or Lost Your Memory Due To A Head Injury / Concussion? YES NO ♦ Please Describe Do You Suffer From Headaches? YES NO ♦ When? Every Day 1-2 Times/Week 1-2 Times/Month ♦ Where Are Your Headaches Located? Left Side of Head Right Side of Head Front of Head Back of Head All Over Your Head Do You Have A History of Migraine Headaches? YES NO ♦ How Often Please Describe ♦ Medications Taken for Migraines? Have You Had Headaches For More Than Three (3) Months? YES NO ♦ If yes, please explain UTD ATHLETIC TRAINING 4 of 8
2013-2014 IX. Orthopedic History Cervical Spine/Neck YES NO Have you ever suffered an injury to your cervical spine/neck? YES NO Have you ever had any diagnostic tests performed on your spine/neck? If yes, please circle all that apply: X-RAY MRI CT SCAN BONE SCAN OTHER _______________ YES NO Have you ever had a “burner”, “stinger”, or other brachial plexus injury? YES NO Have you ever experienced numbness and/or tingling in your arms, hands, and/or fingers? YES NO Have you ever had surgery and/or an injection of any kind to your cervical spine/neck? YES NO Have you ever been advised not to participate in sports due to an injury to your cervical spine/neck? If yes to any of the above, please explain and provide dates below. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Shoulder/Arm YES NO Have you ever suffered an injury to your shoulder/upper arm? YES NO Have you ever had any diagnostic tests performed on your shoulder/upper arm? If yes, please circle all that apply: X-RAY MRI CT SCAN BONE SCAN OTHER _______________ YES NO Have you ever had surgery and/or an injection of any kind to your shoulder/upper arm? YES NO Have you ever been advised not to participate in sports due to an injury to your shoulder/upper arm? If yes to any of the above, please explain and provide dates below. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Elbow/Forearm YES NO Have you ever suffered an injury to your elbow/forearm? YES NO Have you ever had any diagnostic tests performed on your elbow/forearm? If yes, please circle all that apply: X-RAY MRI CT SCAN BONE SCAN OTHER _______________ YES NO Have you ever had surgery and/or an injection of any kind to your elbow/forearm? YES NO Have you ever been advised not to participate in sports due to an injury to your elbow/forearm? If yes to any of the above, please explain and provide dates below. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Wrist/Hand/Fingers YES NO Have you ever suffered an injury to your wrist(s), hand(s), and/or fingers(s)? YES NO Have you ever had any diagnostic tests performed on your wrist(s), hand(s), and/or fingers(s)? If yes, please circle all that apply: X-RAY MRI CT SCAN BONE SCAN OTHER _______________ YES NO Have you ever had surgery and/or an injection of any kind to your wrist(s), hand(s), and/or fingers(s)? YES NO Have you ever been advised not to participate in sports due to an injury to your wrist(s), hand(s), and/or fingers(s)? If yes to any of the above, please explain and provide dates below. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Spine/Low Back/Sacroiliac (SI) Joint YES NO Have you ever suffered an injury to your spine, low back, and/or SI Joint? YES NO Have you ever had any diagnostic tests performed on your spine, low back, and/or SI Joint? If yes, please circle all that apply: X-RAY MRI CT SCAN BONE SCAN OTHER _______________ YES NO Have you ever had surgery and/or an injection of any kind to your spine, low back, and/or SI Joint? YES NO Have you ever had numbness/tingling in one or both of your legs and/or feet? YES NO Have you ever been advised not to participate in sports due to an injury to your spine, low back, and/or SI Join If yes to any of the above, please explain and provide dates below. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Hip/Groin YES NO Have you ever suffered an injury to your hip/groin? YES NO Have you ever had any diagnostic tests performed on your hip/groin? If yes, please circle all that apply: X-RAY MRI CT SCAN BONE SCAN OTHER _______________ YES NO Have you ever had surgery and/or an injection of any kind to your hip/groin? YES NO Have you ever been diagnosed with a hernia / sports hernia? If yes, did you have surgery? ______ Yes _____ No Date of Surgery: _________________________ YES NO Have you ever been advised not to participate in sports due to an injury to your hip/groi If yes to any of the above, please explain and provide dates below. ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ UTD ATHLETIC TRAINING 5 of 8
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Medical Health History Questionnaire - University of Texas at Dallas

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